REPUBLIC OF THE PHILIPPINES )

CITY OF __________________ ) S.S.

RELEASE, WAIVER AND QUITCLAIM,

WITH UNDERTAKING

I, ____________________, ____ years of age, Filipino, single/married, with

residence and postal address at ____________________________, after having duly
sworn to in accordance with the law, depose and state: That --

1. I have received the deposit under savings account no. :

__________________________ in the total amount of
_____________________________________________________(P_________
_________)from
_____________________________________(___________);

2. To my complete and full satisfaction, I hereby RELEASE AND

DISCHARGE _____________, to the extent of the amount of
P_________________. Likewise, I hereby release its officers, employees,
agents or representatives, from any and all liabilities whatsoever emanating,
directly or indirectly, from the release of deposit; And for this purpose, I hereby
hold ________________ and its officers, employees, agents or representatives,
legally free and harmless from any and all liabilities or claims arising thereto;

3. Should ____________________ and/ or the latter’s officers, employees, agents

or representatives be held liable/accountable for whatever reason as a result of
such RELEASE, I hereby agree and undertake to fully assume the same, and
shall indemnify, to the extent of the amount of P______________,
________________and/or the latter’s officers, employees, agents or
representatives either by refunding the same upon demand, or indemnifying the
former for whatever losses or damages that may arise by reason of the
foregoing;

4. Finally, I hereby declare that I have fully read and understood the contents of
this document and that this Release, Waiver and Quitclaim, with Undertaking
is made freely and voluntarily, with full knowledge of my rights under the law.

IN WITNESS WHEREOF, I have hereunto set my hand this ___ day of ______
2018 in ________________, Philippines.

_____________________
Claimant

SUBSCRIBED AND SWORN TO before me this ___ day of ____________,

2013. The Claimant exhibited to me his/her Identification Card No. _________ issued on
____________ at ______________.

Doc. No. ___:

Page No. ___:
Book No. ___:
Series of 201__.